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12/30/2014 01 :50 IFAX isacramt @eastbaytire. com Dianne Amaral IA 010/015 <br /> Tall Free 1-866-896-0600 / www.calrecy_cle.cagoy/Tim/ <br /> Dept.of Reeouroy R"PnB and Rocary <br /> 10 CA Comprehensive Trip Log and receipts 10002 P.D.Bpx IM,Saorarmento,CA 05812-1"250 <br /> Com rehensive THE Nur"ber <br /> C�RtcICie � X A M P LE1 2 3 �! - - <br /> c4iftt�RMMIZa1VINSTRUCTIONS ON BACK OF PART 2 DO NOT TAPE,STAPLE OR-DUPLICATE <br /> By al{afng We OA OamPreherwdvv TO)Lop PM 11806%0%alWtorle}requim drat the Inrormapon prwided an He lora Will be oanYdered oonpdenp•6 proprietary end Irede eeoret.In eeeereeeee vrld,T11%14 CCR,SeCeon <br /> +7541 N m,If a request U meas ror QleobeWe Dr Shia Irdprmerttm,OelReoyale wig eemeel the elpn.l{e)of thle farm N the addreee end Vm one numw proNd•d an Shia ram orFly <br /> L <br /> }:=:•., T >rf:; .:�' - if:' " Hauler Addressc1st C;L) 9fi –� <br /> Business Name + 1 li1 <br /> I <br /> Address , �.F°:1 �• � (� I <br /> City,State and Zip <br /> [l Common <br /> LJ Carrier <br /> I c.nlh urdr Pity of pwluh oaaerthe tewe of ae 31015 of Callfomla 1 l the Infp,aW10n p,aNdad above I Irue end aotry0r.In 40alpon,I all erere that feWlkallan of Ihle Ottormallan may nqulr M ewpv,40n.ra Llon,or denlel of lenewel of <br /> the Weal*Tlrq Hyuler atretbn pureuea to Publlo Aeeouron ate 42990 And mey reaull In aIVII P-111"up to{25.OP0 f V151eVon ore ■up ra$5,000 Per•iolatlon per day ae devaabed In Publlo Reap—m <br /> Code Pollan 4y99$ -.. <br /> river's Naj Driver's S! rA Data <br /> Comprehensive • r Site Suffix <br /> 4661.25-8 I 2 W -� <br /> Hauler Tire Pr6gram'1D It Sites-suffix Facility-Telephone Number <br /> a yk. s REP 6 HEga ® ® <br /> f� •� ci 1<:LI11 Lj�`l}` -� <br /> f1r <br /> t, 17 — IVE'Ylttr�:Aciclrr_y; •ty (.GlYlra�1C1u <br /> Hauler Name `•"1w t�9i.: <br /> - F N Scrcr�rrlr>s7tc) c'(� <br /> �y Hauler Telephone Number ' =d [� Address Same as Hauler InY JI <br /> I CI:RnFY THAT UNDER PENALTY GIF PEFLIURY OF T <br /> F-yJ: }'s• " ^`'"'Kt." ' '.=r�.'.'�YJY a'.,s •%ry.�' - LAWS OF THE STATG OF CALIFORNIA THAT THI! <br /> `' IN TION PROVIDRDAISOVEWMIM&AWS&CL{OT. <br /> Comprehensive Trip Log Nurnber Load Wormaticni Tire Program <br /> 4661258 '.. r a <br /> { Hauler Tire Prbgram.ID / Ste-Suffix' "� r' It3phone,Namber <br /> 000 � oo <br /> AN0.1,?k �..K" -f <br /> ";n. <br /> Hauler Name <br /> w " Hauler Telephone Number = Address Same as Hauler <br /> F r'f:'"' F,ti�'F'•'.,',�,� °�'"� w� °` r lk :'! IOERrIFY <br /> Z THAT UNDER PENALTY OF PMUR,r OF THE <br /> �t N } a��' LAWS OF THE STATE OF CALIFORNIA THAT THE <br /> j`r' •� w INFORMATIONINKMATION PROVIDED OVE IB TRUE ANO CORK T. <br /> i <br /> L3EL 1:ff�:C'T��iBi�fr{5T V5`9T�1T I n a� ry_ ;: :l��l II <br /> 46612.5 <br /> Hauler Tire Program'ID IS t i g ul pxC +ry e' "I�lumber <br /> [ <br /> etiIQC,t1�,!r"t}zirf''T•4 r):7iIcU. ,V R HKE <br /> "Q r i fliYlv.r;,'rYIQI 111:s t+11j] <br /> ,yTatresr}gA>;l.'S ti••rr Gx"!ti•?.�?yt;�t-x>'S y'1Y�c r^.tti�i l.'Ya.4 ;1L1'� 3.. .r it ,, <br /> ,.-'- ---�_. .. ._. C.".}a!3 �!-t� btt� 24}•f.,� ';-ItL1v.' �(..'E'.l ? i�-�'�It::it:G:ire,�r.:i::sc�i.'.LVA�':c�.'.+'i•Y:.,.t.._ J <br />